Direct approach to hip replacement

Published 12:51 pm, Wednesday, January 23, 2013

Photo: Nick De La Torre, Staff

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Jill Porter, of the Texas Super Team weightlifting team and world title holder, shows off her recently developed triceps, Wednesday, Jan. 9, in Monster Gym in Kingwood. Porter is planing on having a hip replaced with a new less invasive method. ( Nick de la Torre / Houston Chronicle ) less

Jill Porter, of the Texas Super Team weightlifting team and world title holder, shows off her recently developed triceps, Wednesday, Jan. 9, in Monster Gym in Kingwood. Porter is planing on having a hip ... more

Photo: Nick De La Torre, Staff

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Jill Porter, a world-class powerlifter, decided to have direct anterior hip replacement surgery after hearing that the method boasted faster recovery times and fewer complications.

Jill Porter, a world-class powerlifter, decided to have direct anterior hip replacement surgery after hearing that the method boasted faster recovery times and fewer complications.

Photo: Nick De La Torre, Staff

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Tiny Meeker, coach of the Texas Super Team weightlifting team, left, talks about teaching technique and muscle usage with one of athletes Jill Porter, who's a world title holder, Wednesday, Jan. 9, in Monster Gym in Kingwood. Porter is planing on having a hip replaced with a new less invasive method. ( Nick de la Torre / Houston Chronicle ) less

Tiny Meeker, coach of the Texas Super Team weightlifting team, left, talks about teaching technique and muscle usage with one of athletes Jill Porter, who's a world title holder, Wednesday, Jan. 9, in Monster ... more

Photo: Nick De La Torre, Staff

Direct approach to hip replacement

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Jill Porter is a lifelong athlete who pounds the pavement on courts and fields across a variety of sports.

So when her left hip started hurting, she hoped it was something that rehabilitation and anti-inflammatories would take care of.

"But it progressed so quickly, I couldn't even walk down my sidewalk and over to the neighbor's house," said Porter, 59. "It was so painful."

Porter needed a hip replacement. The very idea terrified her.

"Both my parents, at one time or another, had hip replacements, and I saw what they went through," Porter said. "In the back of my head, I wondered if something was wrong with the methods surgeons were using."

Porter searched the Internet and found a Houston surgeon performing hip replacements a new way that boasted faster recovery, fewer complications and a smaller incision.

Porter is a world champion powerlifter, so downtime is not something she's fond of. She had the surgery Sept. 12 last year, left the hospital Sept. 14 and planned to compete again this weekend.

The procedure Porter underwent was a "direct anterior" hip replacement. Her physician, Dr. Stefan Kreuzer, has performed more than 2,500 of these surgeries over the past eight years.

"When we first started out, there was a lot of skepticism and not a lot of literature to back our claims," said Kreuzer, who operates out of Memorial Hermann Memorial City. "But people began to see that our patients are off the walker and not on any pain pills one to two weeks after surgery."

The posterior approach involves cutting buttock muscles to get to the hip joint. Since buttock muscles are the main power source when people go from sitting to standing, Kreuzer said that having to go through those muscles surgically poses a significant risk of frequent, post-operative hip dislocations.

The anterior lateral approach lessens that risk because it cuts through the hip abductor muscles instead. Since those are the muscles that stabilize the pelvis, it comes with another risk: Kreuzer said up to 30 percent of such patients will end up with a permanent limp.

The newer direct anterior approach typically doesn't involve cutting through muscles, Kreuzer said, and the much-smaller incision is in the pelvic area. Kreuzer said the dislocation rate is minor and patients don't have to worry about a limp.

Anybody that has arthritis is a candidate for the direct anterior approach, Kreuzer said, although the risk of complications such as infection may be slightly higher in patients who are morbidly obese.

"In my opinion, this is the superior way of doing hip surgery," Kreuzer said. "It's been done in Paris for 30 years, and now patients in the U.S. are learning about it and demanding it. There is no doubt in my mind that in 10 years this will be the predominant way."

However, not all surgeons are embracing it. One downside, said Kreuzer, is that it requires a substantial investment in new surgical equipment as well as learning the technically difficult procedure.

Parsley called the direct anterior approach marketing hype and compared it to what happened when resurfacing hips instead of replacing hips made the news several years ago.

"The popularity of hip resurfacing has risen and fallen three times in my 24-year career," Parsley said. "Marketing had people thinking it was the greatest thing since sliced bread, when it was really a bunch of baloney. That's a little like what's happening with the anterior approach to hip replacement surgery now."

Parsley said the direct anterior approach actually has a 3 percent to 4 percent higher complication rate than more traditional methods and that cutting through muscles is still part of the surgery.

He added that 98 percent of hip replacement surgery results in a marked improvement in the patient's pain and function.

"The most important aspect of a successful hip replacement is having an experienced physician and a very motivated patient," Parsley said. "Establish trust with your surgeon. Let him do the operation in the way he feels most comfortable … and it should last you a good 25 years."

Tim Cox, a 60-year-old Houston resident, had a right posterior hip replacement in August 2003. He had a left anterior hip replacement in July 2004. Today, both hips feel great, Cox said.

But Cox swears that recovery from the direct anterior approach was significantly better.

"I'm not kidding you, I got up and walked that afternoon," he said. "I got out of the hospital the next afternoon. I went back to work with a cane the day after that and went horseback riding a week later. I can't even describe it. It's nothing short of a miracle."